Oxford Clinical and Academic Gastroenterology video transcript SEQ 1 INTRODUCTION COMMENTARY Gastroenterology has been a leading specialty in Oxford since the 1950s but in 2010 a new unit opened here at the John Radcliffe Hospital. Headed by Professor Fiona Powrie, the Translational Gastroenterology Unit is one of the premier facilities of its kind in Europe and provides care for inflammatory bowel disease, nutrition, hepatobiliary disease and other related disorders. Dr Simon Travis, Consultant Gastroenterologist I/V It’s great to welcome everyone to Oxford and to the Oxford Translational Gastroenterology Unit. What we’re going to show you is around the unit so that you get an idea of what it’s like to work in Oxford. COMMENTARY The unit is both a local and tertiary referral centre and cares for over 3500 patients with inflammatory bowel disease every year. Dr Simon Travis, Consultant Gastroenterologist I/V 80 per cent of our patients with inflammatory bowel disease are secondary care. In other words, they are referred direct from their general practitioner and that means that I personally make a diagnosis of ulcerative colitis or crohn’s disease in a new patient every week. COMMENTARY What makes the unit so special is the integration between science, translational research and clinical care bringing both the bench and bedside under one roof. Dr Simon Travis, Consultant Gastroenterologist I/V The laboratories are right next door to the clinical ward, the clinical ward is across the corridor form the cay care unit, the day care unit leads into the clinical trials facility and the difference that makes to our daily working pattern is enormous and you’ll hear from members of the team of how important that is to their daily work. The buzz, the atmosphere is just wonderful. COMMENTARY The team’s multidisciplinary approach to care integrates clinical service and academic gastroenterology with their related specialties. Dr Simon Travis, Consultant Gastroenterologist I/V What compliments the co location is the multidisciplinary meeting. That happens on the Friday lunchtime just before the main IBD clinic. We have the surgeons, radiologists, gastroenterologists but also the pathologists, our nurses, our dieticians and pharmacists. So come with me on a virtual tour of the Translational Gastroenterology Unit and you’ll have an opportunity to meet some of the members of the team on the way. SEQ 2 THE SCIENCE LABORATORIES COMMENTARY The Translational Gastroenterology Unit comprises 250 sq metres of cutting edge basic science laboratories. Dr Oliver Brain, Consultant Gastroenterologist I/V Our state of the art laboratories where we perform basic science are in close proximity to our other gastroenterological services. We have close collaboration between basic scientists, clinician scientists and clinicians and it means that we are able to offer our patients access to truly translational research and ultimately this should lead in the near future to improvements in therapy. COMMENTARY Over 20 basic scientists work within a number of different research groups. Dr Oliver Brain, Consultant Gastroenterologist I/V These include Professor Powrie’s group who leads the unit. Her group is focused predominantly on the cellular and molecular mechanisms that promote immune homeostasis within the gut and in what way this goes awry to lead to inflammation and / or cancer. Professor Alison Simmon’s group predominantly looks at the molecular pathways leading from innate immune signalling and the way in which the innate immune system recognises bacteria and promotes a normal or aberrant immune response. Dr Ben Owens, Postdoctoral Fellow I/V So my research here is focused on intestinal stromal cells. So these are a very interesting population of cells which have hitherto been relatively overlooked in the context of immune responses in the intestine. And we really focus on 3 major areas. One is to identify novel subsets of stromal cells within the human intestine and how these may be related to homeostatic responses and also to inflammatory responses. Two is to profile these stromal cells from defined patients that we have access to through the unit and look at how these stromal cell populations change during inflammation and thirdly is use novel tools that we’re developing in the unit to look at how these stromal cells impact on conventional immune cell function by using three dimensional tissue culture systems that we’re currently developing here. COMMENTARY One of the major benefits of the unit is the ability to access primary human tissue from samples taken at endoscopy or surgery Victoria Morton, Senior Research Nurse I/V So my role within the TGU is essentially in a translational capacity and I’m involved in the recruitment, consenting and processing of samples for a large portfolio of clinical studies. My science background is such that I’m able to process the cells and really get stuck in and work on the projects that are going on here and then when I’m consenting patients in the clinic I’m able to explain to them exactly what we’re doing with their cells in the lab and where their donation of cells is actually going. SEQ 3 THE GASTROENTEROLOGY WARD COMMENTARY Down the corridor from the laboratories is the gastroenterology ward. Here, over 1,500 patients every year are treated for inflammatory bowel disease, liver disease and other related conditions. Dr Arpan Mehta, House Officer I/V There are two teams on the ward. One is the luminal team and one is the liver team. Each team has two junior doctors, two registrars and of course the consultants. Of course we’re very lucky on this ward to have a wide variety of other team members. Of course we’ve got the nurses who are very specialist, dietitians; in fact we have a dietician both on the liver side and the luminal side and we’re supported by a very experienced pharmacist and we have physiotherapists and occupational therapists as well. COMMENTARY Combining gastroenterology and hepatology on the same ward brings frontline care to patients. Dr Jane Collier, Consultant Hepatologist I/V The advantages of having a ward that encompasses both gastroenterology and hepatology is that if there is gastroenterological problem in my liver patients we get expert advice quickly, investigations done quickly and therefore treatment initiated quite quickly and similarly on the inflammatory bowel disease side if they have a patient with liver abnormalities then we’re onsite to sort, investigate and institute management fairly quickly. COMMENTARY The team’s multidisciplinary approach to care is further apparent at the ward meeting held every Wednesday morning. A particular highlight of the week is the weekly strategic meeting. This is attended by a vast number of people right from consultants, junior doctors, nurses, dieticians, pharmacists and even students. It’s a fantastic learning opportunity but more importantly, each patient’s care is discussed in detail and we then go from that setting to the patient as a team and present the conclusions that we’ve come to. COMMENTARY Senior Clinical Fellows also play a critical role in the delivery of clinical care. Dr Kate Williamson, Senior Clinical Fellow I/V There are six senior clinical fellows here at the Translational Gastroenterology Unit and we do 6 clinical sessions, 4 clinics and 2 endoscopy lists and we have 4 academic sessions and our role is to compliment the clinical care here at the John Radcliffe Hospital. We play a big role in helping them manage their clinical trials here and I think that we improve patient care by bridging the gap across multidisciplinary team meetings, clinics and research and we can help co‐ordinate patients’ smooth transition among all of these to get the best possible clinical outcome for patients. COMMENTARY The advantages of co‐located facilities can also be seen here on the ward. Not only is it logistically excellent for transferring of biopsies and samples straight from the lab its also wonderful for the academic environment and collaboration that it fosters and encourages. From the seminars that we have amongst the researchers and scientists and clinicians, right down to corridor conversations and stairwell conversations and the amount of ideas hatched in the corridors is amazing. It’s a really exciting place to be. SEQ 4 THE DAY CARE UNIT COMMENTARY Directly adjacent to the gastroenterology ward is the day care unit. Lydia White, Specialist Nurse I/V I think the IBD nurse role in terms of the IBD patient care and the IBD patient pathway is really central. It tends to be the consistent point of contact for patients. They call us whenever there’s a query, a problem. Because it’s a consistent point of contact and we have the network of the multidisciplinary team, we’re often co‐ordinating things as well as doing treatment and assessment of the patients as well. COMMENTARY The team also offer patients a formal telephone consultation. This is a yearly review for patients who are very stable and they actually phone in to a set appointment time which saves them having to come into hospital when they’re actually well. I think that gives, essentially, patients very good care. SEQ 5 THE CLINICAL TRIALS FACILITY COMMENTARY Right next door to the day care unit is the Clinical Trials Facility. Dr Simon Travis, Consultant Gastroenterologist I/V Oxford is the highest recruiting centre for commercial clinical trials in the country. We have over a hundred patients with active follow up with clinical trials We have 9 different trials in IBD at the moment. These range from phase 2 studies and investigator initiated studies to the commercial, international phase 4 studies. The patients may be involved in studies such as stem cell transplants, the PREVENT study but we’re also doing investigator initiated studies looking at the mechanisms and furthermore we’re doing pre‐clinical work using human tissue. SEQ 6 OUTPATIENTS COMMENTARY The outpatients unit is immediately beneath the gastroenterology ward and the Clinical Trials Facility. Of the 15,000 patients who visit every year, 20 per cent are tertiary referrals. Dr Simon Travis, Consultant Gastroenterologist I/V Outpatient care is of course central to gastroenterology. We have 7 clinics a week in luminal gastroenterology alone. The major IBD clinic on a Friday afternoon, an emergency IBD clinic on a Wednesday but also other clinics which take place on Tuesdays and Thursday as well. Dr Satish Keshav, Consultant Gastroenterologist I/V We’re very proud of the fact that we have a strong multidisciplinary approach to caring for patients in IBD as an exemplar and we extend this to how we look after patients in outpatients. We usually have a dietician, a specialist nurse, we have ready access to endoscopy and to X‐rays when we need a procedure done rapidly. We very frequently have clinics at the same time as colleagues in surgery for instance so if a patient comes to us and the solution is actually surgical we can often send the referral directly or actually take the patient round to the surgeon to have a consultation there and then. SEQ 7 ENDOSCOPY COMMENTARY The endoscopy unit is located next door to out patients. Dr James East, Consultant Gastroenterologist & Endoscopist I/V The endoscopy unit performs around 14,000 endoscopic procedures per year with a full range of diagnostic and therapeutic endoscopy performed in 4 newly refurbished endoscopy rooms taking care of both secondary and tertiary care referrals. COMMENTARY There is also a suite dedicated to research trials of new endoscopic equipment and therapeutic innovation. We are particularly interested in research into inflammatory bowel disease related endoscopy and we have active research projects using advanced imaging techniques including narrow band imaging, autofluorescence endoscopy and pancolonic dye spray. We aim hopefully to combine these advanced imaging techniques with advanced therapy to remove pre cancerous lesions even in inflammatory bowel disease with endoscopic mucosal resection to allow us to avoid major surgery for these patients. COMMENTARY There has been a recognized problem in the validity of current endoscopic scoring systems for colitis. Because of this, Oxford has worked with international colleagues to develop the UCEIS, the Ulcerative Colitis Endoscopic Index of Severity. Dr James East I/V This is important as it enables us to make cross comparisons both between observers within clinical trials and potentially even between clinical trials and is likely to become the definitive endoscopic scoring tool for clinical trials going forward. SEQ 8 SURGERY COMMENTARY The John Radcliffe Hospital has 7 colorectal surgeons and there is always a surgeon onsite, for acute emergencies. Elective surgery takes place at the Churchill site just a mile away. Prof Neil Mortensen, Colorectal Surgeon I/V So the particular surgery we do for IBD is essentially reconstructive surgery as far as we can so for example, patients who have ulcerative colitis have reconstructions with an ileoanal pouch and patients with crohn’s disease if we can avoid resecting their small bowel, we do strictureplastys to preserve small bowel length and that’s a systematic policy or philosophy of our service. SEQ 9 PATHOLOGY & RADIOLOGY COMMENTARY The Translational Gastroenterology Unit is closely integrated with the pathology department, also located here at the John Radcliffe Hospital. Dr Simon Travis, Consultant Gastroenterologist I/V Pathology is an integral part of our team. They come to our multidisciplinary meeting, they’re on call so that if I need biopsies looked at urgently such as to exclude cytomegalovirus in a patient with acute severe colitis I’ll pick up the phone and I will get an answer twelve hours later on a H&E stain. They’re interactive, they help with our research and they offer an excellent service. COMMENTARY Opposite endoscopy is the radiology department who work in close collaboration with the unit. Dr Margaret Betts, Radiologist I/V I think that what makes us unique in the way we care for our patients is that we provide imaging in all different modalities whether that be ultra sound imaging, CT, MR or fluoroscopy and within each of those modalities we do specialist imaging. For example of the gastrointestinal tract, particularly in patients with Inflammatory bowel disease we do MR enterography, CT enterography and I think the fact we can provide every modality it means that with our clinicians we can work out the best test for the patient. SEQ 10 THE FUTURE Dr Simon Travis, Consultant Gastroenterologist I/V So the future of Oxford gastroenterology is really exciting. Our plans are to build an institute of gastroenterology in the next 3 ‐ 5 years. We’ve started on that. The vision is to an institute for immunobiology and translational medicine addressing the pathogenesis, translational medicine and clinical care of inflammatory bowel disease and also liver disease. Oxford is very special because we have together a wonderful diversity of people working in science and clinical care from around the world and that’s what is taking Oxford into the future, into the institute and onto 2018.